eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Oral Malignant Melanoma: Treatment & Medication

Author: Bobby Collins II, DDS, MS, Associate Professor of Oral and Maxillofacial Pathology, Department of Diagnostic Sciences, University of Pittsburgh School of Dental Medicine
Coauthor(s): E Leon Barnes Jr, MD, Professor of Pathology and Professor of Otolaryngology, University of Pittsburgh School of Medicine; John Abernethy, MD, Winston-Salem, North Carolina
Contributor Information and Disclosures

Updated: Mar 21, 2008

Treatment

Medical Care

Medical therapy is not often beneficial for treating oral melanoma.

• Drug therapy (dacarbazine), therapeutic radiation, and immunotherapy are used in the treatment of cutaneous melanoma, but they are of questionable benefit to patients with oral melanoma. Dacarbazine is not effective in the treatment of oral melanoma; however, dacarbazine administration in conjunction with interleukin-2 (IL-2) may have therapeutic value.
• Experience with oral malignant melanoma is largely derived from single cases. Anecdotal reports describe success with interferon alfa (INF-A) or hyperfractionated radiation therapy.
• Many cancer centers follow surgical excision with a course of IL-2 as adjunctive therapy to prevent or limit recurrence.
• Because of the rarity of the lesions, assembling a cohort study group to evaluate the different therapeutic regimens is difficult. Hopefully, future research will incorporate standardized multimodal therapy, such as those used in the treatment of cutaneous melanoma.

Surgical Care

• Electrodesiccation and cryosurgery are described as treatment modalities for early, superficial, palatal lesions. However, incomplete removal results in recurrence that may envelop the previous biopsy, excision, or treatment site and interfere with histologic evaluation. These methods have little or questionable benefit in the treatment of oral melanoma.
• Ablative surgery with tumor-free margins remains the treatment of choice. Early surgical intervention when local recurrence is detected enhances survival, because the dismal outcomes are associated with distant metastasis.
  • About 80% of patients with oral melanoma have local disease, and 5-10% of patients present with grossly involved nodes.
  • After complete surgical excision, the local-regional relapse rate is reported to be 10-20%, and 5-year survival rates are clustered around 10-25%, with a reported range of 4.5-48%. McKinnon et al⁶ report that tertiary care centers have the best results.
• Although radiation alone is reported to have questionable benefit (particularly in small fractionated doses), it is a valuable adjuvant in achieving relapse-free survival when high-fractionated doses are used.⁷
• Eventually, multimodal therapy may be proven effective in the treatment of oral mucosal melanoma.
• Neither lymphoscintigraphy nor intraoperative blue-dye sentinel-node biopsy (eg, selective neck dissection) is useful in predicting drainage patterns in oral melanomas.
• Anatomic ambiguity appears to preclude consistent assessment of oral lymphatic drainage patterns when this technique is attempted.
• Surgical lymph node harvesting depends on the identification of positive nodes at clinical or imaging examination.
• Prophylactic neck dissection (ie, elective neck dissection) is not advocated as a treatment for oral melanoma.

Consultations

• Consult the following specialists and facilitate their meeting during head and neck tumor boards to plan the best therapy and aftercare for patients with oral melanoma.
  • Ear, nose, and throat surgeon
  • Pathologist (eg, dermatopathologist and general surgical, head and neck, or oral and maxillofacial specialist)
  • Medical and radiation oncologists
  • Maxillofacial prosthodontists
  • Speech therapist
• The primary concern is ensured surgical removal; secondary concerns deal with restoring function and cosmetic results. If the anatomy restricts ensured removal, medical oncologists and radiation oncologists must provide the most appropriate adjunctive therapy.
• Maxillofacial prosthodontists can provide advice about the appliances available and about tissue requirements for support and retention.
• The involved consultants should be aware of the recall schedule to assess patient progress and adaptation.

Diet

• Depending on the extent of surgery, dietary modifications may be necessary until obturators and dental appliances are fabricated and placed to restore function.
• Chewing and deglutition may be severely compromised, and aspiration may be possible.
• Retraining may be necessary to facilitate swallowing and to protect the swallowing reflex.
• Nutritional counseling is helpful. Loss of teeth and significant bony anatomy make eating difficult. Soft diets are cariogenic and often high in fat and calories.

Activity

• Most likely, surgery results in compromised oral function, which affects speech and nourishment. Rehabilitation and constant reinforcement may be important in restoring function.
• Nurse practitioners and dental personnel must encourage the patient to adopt healthy behaviors, and they must perform thorough examinations to rule out recurrence and to recognize and treat oral disease.

Medication

Chemotherapeutic medications for the treatment of oral melanoma do not reliably reduce tumor volume. Aggressive surgery remains the treatment of choice. Interferon, dacarbazine, and BCG vaccine have been tried with marginal and unpredictable results. New protocols with interferon (Intron A) and other immunotherapies are being investigated.

Multimodal therapy offers the best likelihood of relapse-free survival compared with any single therapy. Kirkwood et al⁸ showed that surgery followed by high-dose interferon alfa-2b in high-risk, cutaneous melanoma appears to be more beneficial than surgery followed by melanoma antigen vaccination. Although not evaluated in mucosal sites, these approaches may provide valuable adjuncts to the treatment of oral mucosal melanoma.

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